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Redefining addiction treatment

April 1, 2011
by Omar S. Manejwala, MD, MBA, FAPA, CPE
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Lessons learned from physician health programs

The value of more intensive service to payers

It's easy to be frustrated when we see individuals continue to cycle through inadequate levels of care. Patients undergo dozens of detoxification admissions, but never enter residential treatment because payers insist they fail ambulatory approaches first.

What do these failures illustrate? In addiction treatment, it illustrates that the discipline of level-of-care decision-making remains grossly underdeveloped.

While ASAM standards for multidimensional assessment and disease management are significant leaps forward, it's still unknown whether the criteria we use to assign an individual (for example, to level II.5 vs. level III.1) are working. In terms of value, this level of care also may not allow individuals to accrue all of the benefits that a higher level of care can offer.

This could be why the vast majority of PHP participants have undergone residential treatment or partial hospitalization with boarding-despite ASAM criteria that would have suggested lower levels of care. In fact, the mean duration of treatment for physicians in residential or partial hospitalization care is over 70 days.

Insisting on these intense levels of service is one of the keys for success. Outpatient care is successful in many cases, but systems must be prepared to make significant investments. That means providing higher levels of care earlier in the disease course, rather than simply expecting existing level-of-care criteria to drive better results.

For this to occur, the value argument will need to be clarified. For example, it's more cost-effective to pay for a full course of residential treatment than multiple detoxes.

To solve the payer problem, the value must be clearly defined. Treatment providers need to clarify the economic value to all parties of the multiple-stakeholder model. The current healthcare climate is trending towards shifting allocation of risk to treatment providers.

One example of this trend is the push for accountable care organizations (ACOs). The apparent mismatch between risk and return to payers has been a longstanding barrier to solid outcomes in addiction treatment. Why pay for more when the benefits aren't clear?

In the current system, payers either don't accrue the benefits associated with superior outcomes, or cannot transparently “see” the improvements. On the other hand, many PHP participants simply pay cash for treatment, and can easily speak to the benefits of their investment.

All stakeholders-employers, families, and patients-have seen significant return on investment from the PHP approach. By tying reimbursements to the best practices seen in physicians' health treatment, all three addiction treatment customers-the individual who selects treatment, the individual who uses it, and the payer-will benefit.

However, providers themselves must take the lead by implementing successful PHP-style treatment and case management, and measuring the results.

Superior addiction treatment outcomes are within reach, but will require bold, innovative approaches that involve value-based reimbursement, multiple-stakeholder involvement, drug screening and contingency management, level-of-care decision making and emphasis on 12-step approaches.

Meaningful collaboration among employers, treatment providers and third-party payers will result in shared value creation that is not possible under current disaggregated approaches.

Psychiatrist Omar Manejwala, MD, MBA, FAPA, CPE, serves as medical director of addiction treatment programs for Hazelden in Center City, Minn. Dr. Manejwala is a fellow of the American Psychiatric Association and a diplomate of the American Board of Addiction Medicine. BACK TO THE APRIL 2011 ISSUE